Obesity: Why you are not always just what you eat
This week is National Obesity Awareness Week, in case you weren’t aware.
Last week I found myself acting as a public health expert witness on a simulated Citizens’ Jury. They were tasked with deciding how a hypothetical £2million should be spent to tackle obesity. I was instructed to make a pitch for the money to be spent on a mass media campaign to promote healthy eating and active lifestyles. Secretly I was rooting for the town planner to win the money to spend on changing the obesogenic environment. What would I really do with £2million to tackle obesity in a media campaign?
The website and media coverage for National Obesity Awareness Week are focussed mainly on encouraging people to eat more healthily and exercise more, and the campaign is designed to coincide with the post-Christmas detox period, much like Cancer Research UK’s Dryathlon challenge. The aim of this media campaign is “to help people to better understand obesity and the simple ways that it can be tackled.” Can the rise in obesity really be tackled in simple ways?
The Foresight report Tackling Obesities referred to a “complex web of societal and biological factors that have, in recent decades, exposed our inherent human vulnerability to weight gain”. The report includes a mindboggling “obesity system map” with energy balance at its centre (page 79). Wired into this is a tangle of over 100 variables directly or indirectly influencing energy balance. Variables include media availability, pressure on job performance, purchasing power, quality and quantity of breastfeeding, and social depreciation of labour. But the media coverage for National Obesity Awareness Week leads us to believe that we can transcend this tangled web simply, by eating better and moving more.
I find myself wondering why this campaign has made no attempt to raise awareness of the social and environmental causes of obesity. In a search of the campaign-related websites and publications, I was hoping to find at least a reference to these complexities, and perhaps a link to further information, but couldn’t find any.
What about the health inequalities of obesity? The National Obesity Observatory presents a convincing picture of a social gradient for obesity; the better off you are, the less likely you are to be obese. The relationship between social status and obesity is stronger for women, and there are also inequalities seen by ethnic group and disability. Here I had a little more luck. The organisation behind National Obesity Awareness Week is the National Obesity Forum, who published a report this week, State of the Nation’s Waistline . This contains an unfortunate misquote from health inequalities expert Professor Sir Michael Marmot in the Executive Summary; “We are failing too many of our children, women and young people on a grand scale. Health inequality, arising from social and economic inequalities, are socially unjust, unnecessary and unavoidable” (which should have said avoidable). However, there is no further discussion of health inequalities in the body of the document or key recommendations.
A further lonely reference to inequalities was found on the associated website, The National Conversation on obesity. In a scenario which asks readers to think about the wider implications of awareness raising media, we are reminded that one of the “potentially ethically problematic aspects” of raising awareness is that inequalities are aggravated. Research shows that the people who are most at risk (for example people living in deprived areas) are least likely to be able to act upon the information given.
The World Health Organization (WHO) Commission on Social Determinants of Health, released a report entitled Closing the Gap in a Generation , which laid out overarching recommendations, including a call to “..raise public awareness about the social determinants of health...” in order to address health inequalities. A number of reasons have been given to explain the apparent lack of action in this area. It might be that professionals are reluctant to raise awareness of issues that are deemed to be too political. It might be that there is a doubt about the purpose; what will people do with this information? There isn’t a clear, simple action that individuals on the receiving end can be advised to take.
As Raphael argues, raising awareness about social determinants of health could lead to citizens’ engaging in public policy processes, through advocacy, unions, or associations concerned with poverty, housing or women’s issues, but that we should allow people to make up their own minds, which is the essence of health promotion, and the essence of democracy.
So, what could I do with £2million to raise awareness about tackling obesity? Last week, as well as presenting to the Citizens’ Jury, I also facilitated a workshop using an adapted version of a board game produced by researchers in the USA. The game gets members of the public debating and prioritising interventions to address social determinants of health, such as childcare funding, the living wage and warm homes. Participants said that talking with others who had direct experience of some of these issues really changed their minds and shifted their priorities. Maybe there should be more investment in providing opportunities like these, to allow people to engage on a personal level in a deeper debate about health and wellbeing.
Further information about advocacy and policy on obesity: briefing statements from the Faculty of Public Health.
Dr Kate Warren is Registrar in Public Health at the HSMC